Is there a home healthcare provider who has not had to deal with “that” employee – i.e., the one who had his/her client sign a week’s worth of documentation for services they did not provide? Usually the agency does not discover fraud was committed by an employee until weeks, months or even years later. Unfortunately it is a major loophole in service provision that relies solely on paper documentation. It is because of incidences like this that the Affordable Care Act (ACA) includes a mandate for states to take measures to reduce fraud and over payments by focusing on prevention rather than the traditional “pay and chase” model of catching those who commit fraud.
On Dec. 13, 2016, the 21st Century Cures Act (CURES) came into law. Section 12006 of the legislation, Electronic Visit Verification System Required for Personal Care Services and Home Health Services Under Medicaid, is a call for action. This section directs states to require the use of Electronic Visit Verification (EVV) for Medicaid-provided personal care and home health services. CURES contains a new Medicaid requirement for use of Electronic Visit Verification (EVV), which allows the individual providing service to record electronically the exact date, real start and end time, and location of a visit. CURES leaves it to states to decide their own implementation strategies, but EVV is required to be in place by 2019 for personal care services, and 2023 for home health services. Failure to meet these deadlines will result in reduction of federal matching funds for those services.
CURES defines “Electronic Visit Verification System” as a system under which personal care services and home health care services visits are electronically verified with respect to:
The type of service performed
The individual receiving the service
The date of the service
The location of the service
The individual providing the service
The time that the service begins and ends
States have an option to choose from three recommended models for implementation:
The Provider Choice model requires the provider to select and fund an EVV solution of its choosing from a vendor whose EVV solution meets requirements and complies with Medicaid rules for electronic documentation. With this model, the state avoids the expense of the procurement process. Data integration for billing authorization may be required. The state may audit the provider for compliance, particularly to review records manually added or adjusted. Providers may be required to justify an excessive amount of edits. This model was used in Missouri, where 600 providers made the transition by mid-2015. Although the providers had to procure, implement and pay for the EVV solution, providers generally supported this choice as the providers were left in control of the vendor and timing.
With MCO choice, managed care organizations are required to fund, select and implement an EVV solution of their choice. This option can be challenging for providers who have little or no say in the vendor chosen or services provided to ensure that the transition is smooth. Where there are multiple MCOs, providers could potentially be forced to use multiple EVV solutions.
The state contracts with a single EVV vendor. This model involves the state procuring, funding, selecting and implementing an EVV solution of its choice and managing the concerns and complaints from providers. With state choice, the providers use a “free” system. Challenges for providers occur if the provider has already selected its own EVV solution, and it could reveal hidden costs if the state-selected system does not integrate with other vendors.
Louisiana has experienced two failed roll-outs at considerable cost and inconvenience to the state and providers.
Open Vendor Model
The state provides an EVV solution while simultaneously allowing providers and MCOs to keep their existing EVV system that is already integrated into their operations. It also allows providers to choose between the state system and a solution of the provider’s choosing. This is the model currently being used in Ohio.
Whether mandated or not, EVV is just smart business and necessary. No agency wants to knowingly submit claims for services that were not provided; yet, they are sometimes at a loss when it comes to preventing this from happening.